The inquest at Flax Bourton Coroners Court is being held in an attempt to find out why she came to fall.

Avon Coroner Maria Voisin was told that Mrs Mohamed had given birth to a baby son in February of that year.

She had become anxious and agitated and feared she would be unable to care for her son properly.

Mrs Mohamed was detained under the mental health act and admitted to Callington Road Hospital in Brislington on March 16, after becoming distressed and threatening to return to family in London with the then three-week-old baby.

Consultant Dr James Eldred, who treated Mrs Mohamed, told the inquest: “She had a high level of anxiety around his welfare and was worried about her ability to look after her baby.”

Dr Eldred said that Mrs Mohamed had initially been agitated and reluctant to engage with medical staff, but after being given medication she had started to become calmer and more lucid.

At a review on March 28 she told staff it had been “good to get her head together” and a visit had been arranged to assess her suitability for a placement at the New Horizons Mother and Baby Unit at Southmead Hospital.

The same day Mrs Mohamed was visited by her husband. She later discharged herself from hospital and went to stay with friends.

A meeting was held at the hospital the following day to discuss Mrs Mohamed’s options and a care co-ordinator, Catherine Phillips from the Avon and Wiltshire Mental Health Partnership Central Assessment and Intervention Team was allocated and a referral to the mother and baby unit completed.

At the time of her admission to hospital the couple’s baby was being cared for by Mr Mohamed’s mother, the inquest heard.

After her discharge consultant psychiatrist Dr Sarah Oke contacted CAIT team mental health nurse Miss Phillips to organise further contact with Mrs Mohamed. But Dr Oke became concerned after she called at Mrs Mohamed’s home and that of a friend with whom she was supposed to be staying but could not find her.

Dr Oke said: “I was worried about her safety. I thought we should try and engage with her and get some clarity on her condition and re-admit her under the mental health act.

“I was concerned she had post-natal psychosis and a proper diagnosis should be made.”

A further mental health assessment had been planned but was cancelled when Mrs Mohamed discharged herself from hospital.

Mrs Mohamed went to stay in London with her family. They took her to see a private doctor, who prescribed her the anti-depressant citalopram and vitamin B tablets, which led to an improvement in her condition.

The inquest heard mental health teams had tried to organise further support in London, but this had proved “practically impossible”.

In June Mrs Mohamed returned to Bristol, saw her GP and was referred back to Miss Phillips.

The nurse said: “Mrs Mohamed expressed a desire to go to the mother and baby unit and pick up where she left off.

“She understood that the family were unwilling to let her care for her son until her mental health had improved.”

Miss Phillips said at a meeting Mrs Mohamed did not present any psychosis or paranoid thoughts. A further meeting was planned in July but Mrs Mohamed failed to attend. Her absence was not followed up.

On the same day Mrs Mohamed had seen her doctor, saying she was feeling anxious and seeing animals that were not there. She asked for anti-psychotic drugs.

Miss Phillips said: “When she didn’t turn up on July 12 I should have immediately booked another appointment.

“There were things in hindsight I should have done, such as contact her at home or Mr Mohamed.”

The coroner heard measures had now been put in place to ensure missed appointments were followed up.

A post mortem revealed that Mrs Mohamed died as a result of a brain injury suffered in the fall.

Toxicology reports showed there was no alcohol and no illegal substances in her blood.